MICAELA KARLSEN, MSPH P L A N T B A S E D R E S E A R C H . O R G

KATHY POLLARD, MS H A B I T S O F H E A L T H . S U P P O R T

P L A N T - B A S E D N U T R I T I O N

H E A L T H C A R E C O N F E R E N C E

S E P T , 2 0 1 5

Dietary Behavior Change: Strategies for Practitioners to

More Effectively Support Patients

Presentation Roadmap

Define the problems and challenges of dietary behavior change

For practitioners

For individuals

Strategies for practitioners

Assessment and goal setting to grow practitioner offerings

Diet Disease or Health

Changing diets can change health outcomes, BUT, as shown by success with weight loss -

Long-term adherence can be difficult to achieve (e.g. only ~20% of adults who lose 10% body weight are successfully able to keep it off for >1 year)

(Wing and Hill 2001)

Challenges for Practitioners

Limitations in effecting permanent dietary and lifestyle change with

patients, when making recommendations

Education Alone Is Not Enough To Effect Change

Providing information without other support or changes is ineffective:

Nutrition facts panel on food

Menu labeling

Dietary guidelines

Implementing school-based education alone

Vending labels alone

Afshin et al., The Handbook for Global Health Policy

Practitioners Have Limited Contact Time

Most payment models don’t facilitate: Treating w/ dietary change

Longer sessions (15+ or 30+ min)

Prevention, counseling, lifestyle support

In behavioral counseling for obesity, more treatment sessions associated with greater mean weight loss

(Wadden, Butryn et al. 2014)

Limited Nutrition Training and Ability To Model

Lack of nutrition training and understanding by practitioner

Limited experience with eating a plant-based diet makes it difficult to speak from personal experience

Physician’s weight status affects willingness to diagnose obesity or speak about weight loss

(Bleich, Bennett et al. 2012)

Challenges for Patients

Specific challenges that make diet and lifestyle change difficult for

individuals to make and maintain

Disordered Eating

Obesity May be normal eaters but overeat

Eating Disorders May be normal weight or thin, but

emotional or spiritual problems

Chemical Dependency on Food Eating certain foods triggers craving

and eating beyond hunger, and in spite of negative consequences

Therapy is not enough; they can’t stop eating

(Food and Addiction, 2012)

Perceived Barriers to Healthy Diets

Randomly selected survey to assess barriers to change in Australia, N=400

Plant-based diet defined as mostly plant food but still including some meat

51% response rate – could significantly bias results

Perceived barriers fairly similar but differed by sex for certain items

(Lea et al., Nature 2006)

Perceived Barriers to Eating Plant-Based Diets

(Lea et al., Nature, 2006)

Food Environment

Built environment obesogenic /disease-promoting environment

Satiety overridden by:

Food accessibility

Eating occasions

Marketing and advertisings (artificial stimulated hunger)

Decreases in:

Physical activity

Cost of calorie-dense foods

(Cohen 2008, Durand, Andalib et al. 2011)

Ecological Model

Bronfenbrenner, U. (1977). Toward an experimental ecology of human development. American Psychologist, 32(7), 513-531.

Policy Initiatives Could Help Shift Environment

10/2/2015

Media and education (as part of larger campaign)

Labeling and information (industry behavior)

Schools & workplaces (comprehensive & multi-component)

Immediate built environment & distance to supermarkets

Economic incentives

Restrictions and mandates (direct & on marketing)

Challenge is that individuals may need to deal with the environment “as-is”

Afshin et al., The Handbook for Global Health Policy

Built Environment Over-Reliance on Willpower

Food environment and hyperpalatable foods lead to inappropriate reliance on willpower

Based on the work of Dr. Roy Baumeister, professor of psychology at Florida State University

Willpower likely evolved to help us navigate tensions inherent in social groups

Primary purpose is NOT what it is used for in the modern environment – to stop ourselves from eating

Willpower is a finite resource that gets diminished in the short term

How Could Changing Diet Happen?

Shay, LE. Nurs Forum., 2008

Willpower Can Help People Force Through

X

When Is Willpower Diminished?

• Lack of sleep • Physical exertion • Long concentration • Decision fatigue

Fatigue

• Low blood sugar

Hunger

The modern food environment could not be better designed to induce decision fatigue around food

Increased cravings, impulsiveness, and intensity of emotion/sensation

200 Food Decisions Daily

We are aware of only a fraction of the food decisions we make

We are either unaware of how our environment influences these decisions or we are unwilling to acknowledge it

Wansink, Environ. & Behav., 2007

The more decisions we make, the less self control we maintain decision fatigue

Why Use Willpower For Food Decisions?

Most people are eating hyperpalatable (intensely rewarding) foods regularly

Added fat

Added sugar or refined carbs

Added salt

Caffeine

Alcohol

Hyperpalatable foods are physically/chemically addictive

Animal Foods Also Foster Addictive Responses

Excess fat

Calorically dense

Potential opiate effect from protein in meat and cheese

Release of insulin Refined foods are more insulinogenic

than traditional whole plant foods

Adding fat and protein increases insulin secretion

Insulin and dopamine systems work together to orchestrate motivation

(Yeomans, Wright, Macleod, & Critchley, 1990, Food and Addiction, 2012)

Most People Experience Some Degree of Food Addiction

Drug addiction and food reward activate similar neural circuitry, as do drug and food cravings

Rats given sugar, fat, or highly processed foods exhibit behavioral signs of withdrawal, tolerance, and continued use despite negative consequences

(Gearhardt, Davis et al. 2011)

Similarities Between…

(Gearhardt, Davis et al. 2011)

Similarly Processed Like Drugs

Elevated potency Rapid absorption into

bloodstream Examples: Coca leaf cocaine or crack Corn high fructose corn syrup

Tolerance develops Cue-reactivity Situations trigger consumption

Increased addictive potential

Symptoms of Physical Withdrawal

• Fatigue • Dizziness • Sweats • Emotional fluctuations • Headaches • Depression • Fainting spells • Shaking • Poor memory

(Food and Addiction, 2012)

How to support patients in permanent dietary and

lifestyle changes

Solutions

Behavior Change Supported By

Effective clinical intervention with a two-way interaction (participatory)

Patients are involved in self-evaluating, setting goals and trajectory, and outlining steps

Practitioner providing additional resources for change Group support

Additional personal contact (health educator or dietitian on staff?)

Resources for learning & skill building

Referrals for social contact with like-minded people

Accountability and high expectations

Modeling

(Sainsbury et al., Int.J. Behav. Med., 2014)

Commitment

Choosing Healthy

Food

Supportive Environment

Social Support

Expectation of Success

Nutrition Knowledge

Cooking Skills

Conceptual Model for Creating

New Habits

Readiness for

Change

Transition to and Successfully

Sustain a Whole-Food, Plant-Based

Diet (Habit)

Motivation

Importance of Habits

Habits strengthened by repetition

Intentions can shape behavior initially, but habits dominate when intentions are weak or unformed, or when willpower is diminished

Habits can be considered “impulsive” behavioral patterns of behavior – they don’t require conscious thought

Habits can be the bain or the blessing of a healthy diet

(van't Riet, Sijtsema et al. 2011)

Breaking Old Habits / Creating New Habits

Changing the environment can facilitate changing behavior Shop in a new grocery store Rearrange the furniture in the house Taking different travel/commuting

routes

Planning the way out of habitual responses Implementation intentions

Create new reinforcements for the new behavior Subtle works better than blatant

Building a Comprehensive Support Structure for Lasting Change

Potential role for physician, healthcare practitioner as facilitator of lifestyle changes

Best chance for success is to make points of contact more than 15-min appt; offer ongoing support and engagement

Building community to creating lasting change

Practitioner Approach for Successfully Empowering Patients

Encouragement

Role modeling

Respecting their ability to create change

Patients setting their own goals

Active engagement in their health process

Caring and compassion by the provider

Greater contact time

(Martin, Williams et al. 2005)

Greater and Ongoing Contact

How much time do you get with patients/clients?

Partner with RD, health educators, coaches

Do you have ways of staying in touch between appointments? Email list

Social media

Group appointments or group events

Network organized among your patients (patients can meet without you)

Considerations for Particular Subgroups

Cost, convenience, and physical availability are major determinants of food purchasing for low-income people

Those living in food desserts need realistic options for inexpensive, healthy meals

(Budzynska, West et al. 2013)

McDonalds Groceries Purchased at Walmart

2 Big Mac Meals = $12.38

2 Cheeseburger Happy Meals = 6.58

Tax = $1.14

Total: $20.10

Spicy Black Beans = $6.77

Savory Brown Rice = $1.99

Steamed Herb Vegetables = $3.99

Salad with Dressing = $5.08 No Tax

Total: $17.83

Meal Cost Comparison – Dinner for 4

Practical Suggestions for Implementation – Consider Your

Practice & Self-Assess

Establishing Credibility / Inspiring Follow-Up

Offer materials to read before the visit, in the waiting room, or as a follow-up

A personal statement about using nutrition to treat the cause of illness

Your own experience with a healthy diet?

Inspiring stories from your other patients (of co

A brief pamphlet on nutrition and disease

Movies

Books

Assessment Before the Appointment?

Initial intake survey can include questions such as: Knowledge of nutrition

Biggest problems or issues of greatest importance

Self-rating of motivation to change diet

Fears or concerns

Self-assessment of nutrition knowledge

Self-assessment of cooking skills

Rating for family and friend support, other social environment support

Can prompt individual to self-reflect and start the goal setting process

Education and Skills/Environment Training

What do you provide to patients to support their learning and skills development? Printed materials in your office?

Electronic materials, links, referrals through your website?

Cooking instruction or referral to online videos?

Live, phone, or webinar trainings on creating a supportive physical environment?

Group appointments or sessions with a staff dietitian?

PLANTBASEDRESEARCH.ORG/RESOURCE -WIKI

Community Resource Wiki

Shared Wiki Document – anyone can edit – free for all to use

Facilitate Creation of a Supportive Environment

Suggestions for the home and workplace

Lists of area restaurants, grocery stores, online shopping options

Social network shared culture

Social Support and Ongoing Contact Through Practice

Email contact – consider using an email client to schedule automatic follow-up emails and event reminders

MailChimp

Aweber

Constant Contact

Follow-up appointments with staff educator or dietitian

Support group based at practice office

Group appointments

Group Appointments CPT Codes

www.aafp.org/practice-management/payment/coding/group-visits.html

http://www.womensportsnutrition.com/images/lts.CPT_CODES_-_ALL.pdf

Social Support and Ongoing Contact Through Outside Opportunities

Facilitate patients to connect with each other Facebook group for your practice?

Social gatherings?

Referrals to plant-based social media to seek new friends?

Suggest sharing their new food with friends – without trying to “convert” anybody Leads to greater appreciation and support for what they are trying to do

Suggest a support buddy

Referrals to Meetup groups / PlantPure Pods / local groups

Consider Program/Facility Referrals

Center for Nutrition Studies eCornell Certificate Program True North Health Center Dr. Stoll’s Total Health Immersions Retreats CHIP - Complete Health Improvement Program Ornish Program Reversing HD PCRM 21-Day Kickstart Local programs or WFPB Experts Plant-based RD or Nutritionist Culinary RX Program and TPP Quick Start Guide McDougall Health Clinic Engine-2 Programs Montgomery Heart & Wellness - Houston Global Roots Total Health Experience in the DR Oct 15 AND MANY MORE…

Using The

SMART Goals Model

Goal Setting for Action

Mapping Your Resources

Continued Contact

Education

Training

Social Network Building

Consider getting an accountability partner to strengthen your commitment

Specific

Measurable

Actionable

Relevant

Time-limited

SMART Goals Model for Effective Action

Goal Setting

Ongoing Contact

Inspiration & Modeling

Education

Skills Training

Social Support

Time limit _________

Time limit _________

Time limit _________

Time limit _________

Time limit _________

ADAPT Survey Thank You

Learn more at hnrca.tufts.edu/studyadapt

MANY THANKS to all who participated in the ADAPT

Feasibility Survey on popular diets at Tufts!

Many Thanks to Friends, Family, and Mentors

Thank You